On March 31, 2020, the Department of Insurance issued Bulletin B-0016-20 to issuers of health plans that are not required to comply with the ACA (alternative health plans), including discount plan operators, third party administrators, fixed indemnity health insurers, health care sharing ministry operators, direct primary care plan operators and travel insurers. The bulletins and the rule are primarily directed at insurers. However, employers should also be aware of these developments.
- Waiving copayments, coinsurance and deductibles for COVID-19 testing and to cover the full cost to get the test
- Waiving consumer cost sharing and facilitate expanded use of telemedicine
- Covering necessary medical equipment, supplies and services
- Waiving penalties, restrictions and claims denials for necessary out-of-network services
- Waiving requirements for preauthorization, referrals, notification of hospital admission or medical necessity reviews for care consistent with CDC guidance
- Allowing extra time for health providers and facilities to file claims
- Authorizing payment to pharmacies for up to a 90-day supply of any prescription medication for individuals, regardless of when the prescription was filled
- Waiving copayments, coinsurance and deductibles for qualifying coronavirus preventive services as defined under the CARES Act
- Explaining how they cover COVID-19 testing and treatment
- Reporting what they are doing to the department
On April 1, 2020, the Department of Insurance issued Bulletin B-0017-20 to exclusive provider networks and HMOs, expecting them to provide coverage for COVID-19 testing and to make sure their networks are adequate to deal with the COVID-19 outbreak.
On April 1, 2020, the Department of Insurance promulgated emergency rule 28 TAC §35.2, which applies to health benefit plans regulated by the state. The rule became effective immediately and:
- Authorizes payment for an additional one-time 90-day supply of any drug that is covered or required to be covered and as prescribed under the authority of a licensed health professional for insureds, regardless of the date on which the prescription has most recently been filled
- Makes an insured liable only for copayments, coinsurance or other cost sharing as if a prescription drug is dispensed out-of-network, when no reasonably available in-network pharmacy is able to timely dispense a prescription drug prescribed under the authority of a prescribing health professional
- Requires health plans to make alternative drugs available on-formulary or in the same preferred tier when an on-formulary or preferred drug is unavailable due to shortage or lack of distribution. The health benefit plan may not require prior authorization for the alternative drug and may not force an insured to travel more than 30 miles one-way in order to obtain it
- Prohibits health plans health from requiring an insured's signature at the point of delivery of a prescription drug unless the signature is otherwise required by law
- Prohibits health plans from refusing or reducing payment for a prescription drug based solely on the grounds that the prescription drug was delivered by a local pharmacy to the insured
The bulletins and the rule are primarily directed at insurers. However, employers should also be aware of these developments.
Bulletin B-0016-20 »
Bulletin B-0017-20 »
Emergency Rule 28 TAC §35.2 »